TCTAP 2026
Left Main Revascularization Hinges on Individualized Choices Beyond Trial Headlines N
At TCTAP 2026, Sripal Bangalore, MD, MHA, professor of medicine at NYU Grossman School of Medicine and director of invasive and interventional cardiology at Bellevue Hospital Center, reviewed contemporary evidence comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main and multivessel coronary artery disease, framing the debate as a decision that had moved beyond a simple “PCI versus surgery” binary. He opened with a 72-year-old woman with Canadian Cardiovascular Society (CCS) class III angina, a positive stress echocardiogram, normal ejection fraction, severe calcification of the left main, ostial LAD, and LCX, and severe Medina 1,1,1 left main bifurcation disease, underscoring that both strategies offered meaningful but different tradeoffs. No Overall Mortality Difference, but Important Subgroup Signals Drawing on a meta-analysis he co-authored (Kuno, Bangalore et al., American Heart Journal 2020) of four randomized trials—EXCEL, NOBLE, the SYNTAX left main subgroup, and PRECOMBAT (n=4,394, follow-up ≥5 years)—together with the patient-level meta-analysis by Sabatine et al. (Lancet 2021;398:2247-57), Bangalore concluded that there was no overall mortality difference between PCI and CABG in left main disease. The recently reported NOBLE 10-year final results (Holck et al., Lancet 2026;407:1374-82) reinforced this finding, with all-cause mortality of 23% in the PCI arm versus 25% in the CABG arm (HR 0.93; 95% CI 0.74–1.18; p=0.56) and no significant interaction with SYNTAX score. He highlighted two clinically important subgroup signals. First, in the NOBLE acute coronary syndrome (ACS) cohort, PCI was associated with significantly lower long-term mortality than CABG (HR 0.57; 95% CI 0.32–0.99; p=0.047), suggesting that the physiology and urgency of ACS may have favored a less invasive upfront strategy in selected patients. Second, in pooled meta-analytic data, there appeared to be a possible advantage of CABG for cardiovascular death—not all-cause mortality—only at very high SYNTAX scores, indicating that anatomic complexity remained relevant for that specific endpoint at the most complex end of the spectrum. Tradeoffs Beyond Survival Bangalore explained that, across pooled trial data, CABG generally reduced spontaneous myocardial infarction and repeat revascularization, while PCI was associated with fewer peri-procedural complications, lower early stroke risk, and faster recovery. In the EXCEL quality-of-life analyses (Baron et al., JACC 2017;70:3113-22), PCI was associated with earlier improvement in physical function (SF-12 Physical Summary), dyspnea (Rose Dyspnea Scale), depression (PHQ-8), and angina frequency (Seattle Angina Questionnaire), with most differences narrowing or resolving by 12 to 36 months. His central message was that “patient preference matters,” particularly when weighing short-term risks of death and stroke with CABG against long-term risks of repeat revascularization after PCI. Table 1. Clinical tradeoffs in PCI versus CABG decision-making Domain PCI CABG Early recovery Generally faster Longer recovery Early procedural burden Lower peri-procedural complications in selected patients Higher short-term surgical risk Repeat revascularization Higher risk Lower risk Spontaneous MI Higher than CABG in pooled datasets Lower risk Stroke / peri-procedural events Lower early burden Higher peri-procedural burden Mortality signal in subgroups Possible benefit in ACS cohort (NOBLE 10-year) Possible benefit for CV death at very high SYNTAX scores Best suited for Equivalent complete revascularization achievable, lower anatomic complexity, high surgical risk, ACS in selected patients, patient preference Complex anatomy, very high SYNTAX score, durable complete revascularization Guidelines and Patient Selection Bangalore placed his conclusions in the context of the 2021 ACC/AHA/SCAI revascularization guideline, of which he was a co-author (Lawton, Tamis-Holland, Bangalore, et al., JACC 2021). The guideline recommended CABG to improve survival in patients with significant left main stenosis (Class 1), while stating that PCI was reasonable (Class 2a) in selected stable patients for whom PCI could provide equivalent revascularization to that possible with CABG. He also cautioned that the mean age of patients enrolled in the four landmark trials had ranged from 62 to 66 years (PRECOMBAT 62; SYNTAX 65; EXCEL and NOBLE 66)—considerably younger than many patients encountered in contemporary practice. Direct extrapolation of these results to substantially older patients, including the 72-year-old in his opening case, therefore required caution. Conclusion Bangalore concluded that revascularization choice should be individualized by a Heart Team, weighing the ability to achieve complete revascularization, short- and long-term event risks, clinical presentation (including ACS status), anatomic complexity at the highest SYNTAX tier, frailty, age, and informed patient goals. TCTAP Workshops Left Main & Multi-Vessel Disease: Modern Evidence and Real-World Strategy Thursday, April 30, 2:50 PM ~ 4:25 PM Main Arena, Level 1 Watch Session Video
May 14, 2026 78
